MaleFemale













SingleMarriedDivorcedWidowed


WhiteAfrican AmericanHispanic/LatinoAsianOtherDecline to answer

StandingSleepingTwistingSittingBendingLiftingWalkingSneezingCoughingLying DownSexual ActivityOther

ImprovingGetting WorseAbout the sameIntermittent (come & go)












Auto AccidentWork RelatedFall






EatingBathingToiletingTransferringDressingGroomingSleepingThinkingSittingWalkingStairsReachingLiftingBendingStoopingKneelingSquattingGraspingWeakness





AsthmaBowel disorderCancerDepressionDiabetesBladder disorderHeart diseaseKidney diseaseLung diseaseBronchitisTuberculosisStrokePolioHigh Blood pressureRheumatismSeizureMental IllnessThyroidUlcer



DiabetesRheumatoid arthritisBack problemsCancerTuberculosisHeart AttacksHypertension











double visionblurred visionringing in the earsdizzypoor hearingsevere headachesevere recurrent nose bleeddifficulty swallowing

dull chest painpressure/tightnesschest palpitations (fluttering)shortness of breath at restshortness of breath with exertionshortness of breath when lying flatcoughingcoughing up bloodswelling feetsevere sweating at night

abdominal painvomitingvomiting bloodblack & tarry stoolbloody stoolsclay colored stoolsloss of bowel controldramatic change in bowel habitsjaundice (yellowing of skin, eyes)

burning on urinationblood in urineunitary frequencyloss of bladder controlpenile or vaginal dischargepenile or vaginal bleedinggenital sores

joint painjoint swellinggrinding of jointslocking of jointsneck painback pain

feverchillsnight sweatsloss of appetiteunintentional weight loss

Paralysis in arms or legsnumbness in arms or legsloss of consciousnessseizurestremorsjerkingpoor coordination

loss of hairdry soresitchinessrashes

increase thirstexcessive urinationexcessive drinkinghot/cold intoleranceexcessive sweating

The Patient hereby consents to the use or disclosure of his/her individually identifiable health information "protected health information" by Fakhoury Medical and Chiropractic 1009 SW 16th Lane Ocala FL 34471, in order to carry out treatment, payment, or health care operations. The Patient should review FMCC's Notice of Privacy Practices for Protected Health Information "attached" for a more complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this consent form.

FMCC reserves for itself, the right to change the terms of its Notice of Privacy Practices for Protected Health Information at any time. If the FMCC does change the terms of its Notice of Privacy Practices, The patient may obtain a copy of the revised Notice by written request.

Patient retains the right to request that FMCC further restricts how his/her protected health information is used or disclosed to carry out treatment, payment, or health care operations. FMCC is not required to agree to such requested restrictions; however, if FMCC does agree to Patient's requested restrictions, such restrictions are then binding on the FMCC.

At all times, Patient retains the right to revoke this Consent. Such revocation must be submitted to the FMCC in writing. The revocation shall be effective except to the extent that the FMCC has already taken action in reliance on the Consent.

FMCC may refuse to treat Patient if he/she (or an authorized representative) does not sign this Consent Form (except to the extent that the FMCC is required by law to treat individuals). If Patient (or authorized representative) signs this Consent Form and then revokes Consent, the FMCC has the right to refuse to provide further treatment to Patient as of the time of revocation (except to the extent that the FMCC is required by law to treat individuals).

I wish to have the following restrictions to the use or disclosure of my health care information:









I understand that I am responsible for any co-payments or deductibles not covered by the applicable personal injury protection (PIP), Medical payments, or other insurance coverage.

This assignment includes, but is not limited to: All rights to collect benefits directly from any insurance carrier obligated to provide benefits for services and supplies I have received. All rights to take legal or other action against any insurance carrier obligated to provide benefits if for any reason the insurance carrier fails to pay any benefits due; and All rights to recover attorney fees, legal assistant fees, costs, and any interest on fees and costs, for any legal or other action taken by Fakhoury Medical and Chiropractic Center as my assignee.

This is an assignment of rights only, and is not a delegation of any of my duties under the subject insurance policy.

I agree that Fakhoury Medical and Chiropractic Center may retain any attorney it chooses to bring legal action against any insurance carrier obligated to provide benefits for services and supplies I have received, and that the attorney chosen may be different than any attorney I may have handling any claim I may have for personal
injuries.

I may be given a copy of this assignment to retain for my records if requested; I have read this assignment and I am satisfied that I fully understand the purpose and implications of executing this assignment and do so freely and voluntarily.



I, the above named insured, hereby authorize and direct the above named insurer to send to Fakhoury Medical
and Chiropractic Center, 1009 SW 16'h Lane., Ocala, Fl 34471 (352) 351-3413 FAX (352) 629-6667, an accounting of payouts made under all claims submitted for payment under the above referenced policy relating to the automobile accident occurring on the above referenced date as those payouts occur.